Bearing witness to healthcare history

Picture credit: Deepali Yakkundi

Indira Chakravarthi, Shweta Marathe and Benjamin Hunter reflect on the experience of designing and hosting a witness seminar in June on the evolving private healthcare sector in Mumbai and Pune, two important cities in the western region of Maharashtra, India.

Documenting private healthcare transformation

The private healthcare sector in Maharashtra has undergone significant transformation in recent decades amidst economic, social and political shifts, leading to changes in the composition, organisation and financing of healthcare. The number of private healthcare providers has increased, and larger hospitals offering multiple, on-site, high-technology services are the preferred choice for many users. Historically, hospitals in Mumbai and Pune have held charitable trust status but these hospitals have increasingly mimicked behaviours of the for-profit providers. In some cases private for-profit providers have been contracted to manage the trust hospitals.

New markets have also emerged, including single-specialty chains, home-based care and online platforms for booking consultations. The expansion of insurance markets is particularly significant. For the poor, there has been sustained interest in developing public insurance programmes to finance hospital care. For the middle classes, private insurance has become important, offered as an employer benefit or purchased independently. Together these represent an important shift away from out-of-pocket payments and towards ‘cashless’ service provision.

The challenges of organising a witness seminar

We wanted to document the experiences of those who worked in and around the healthcare sector during this period of transformation, to gain detailed insights into how such changes play out. The witness seminar method is particularly appropriate for data generation on recent developments or events of significance. It brings together a small group of people and invites them to discuss and reminisce regarding their first-hand experiences of an event or process, with the meeting transcript usually being made publicly available afterwards. Transcripts from witness seminars allow us to see beyond official reports, press releases and academic texts, to gain behind-the-scenes insights into the personal relationships, experiences, and processes that underpin policy change and institutional transformation. Witness seminars have been used extensively by the Institute of Contemporary British History at King’s College London, and by the History of Twentieth Century Medicine Group at Queen Mary, University of London. To the best of our knowledge this was one of the first times that the witness seminar method had been used in India for studying contemporary healthcare events, and its novelty attracted interest from other researchers who attended the seminar to learn more about its procedure and scope.

The chief difficulty for us lay in designing a witness seminar that could adequately capture details spanning a broad period of time and where the processes of change can be diffuse and gradual. We found a transcript on broader transformations in UK public health particularly useful for informing our plans. Identifying and convincing (often with the help of colleagues such as Dr Arun Gadre) key persons from the public and private sectors to be witnesses who could articulate their experiences was a crucial initial task. An important learning was the need to prepare detailed information on the background of the potential witnesses, in order to be able to design key questions to be directed to them. Deciding about the optimal number of witnesses and whether or not to have an expert audience were other important issues that we had to address.

Over two-three months, we and other project team members put together a background note covering important policy measures and other developments to guide the selection of key topics, identified and contacted a short list of potential witnesses, and shared information with them about witness seminars in general and the aims of this one specifically. We worked with the seminar chairs Professor Ramila Bisht and Professor Susan Fairley Murray for two days before the seminar to develop a detailed set of questions and prompts to guide discussion, tailored to the biographies of the witness seminar participants. This task of broadly ‘scripting’ the seminar – putting together the specific questions to get the discussions started by key witnesses – proved to be extremely useful in keeping the proceedings structured and within time, and not letting the discussion drift into generalised opinions and views on the private healthcare sector.

Last minute hiccups

Three witnesses pulled out in the days running up to the witness seminar, one of which posed a significant problem as they were to provide an industry perspective on the changes. As others have noted, such challenges are inevitable when participants are elderly, but they are also an issue for seminars seeking to bring together people who are influential in their field and are still working; who risk being called away for work at short notice. In this case we were able to draw on the network of one of our remaining key witnesses to identify and persuade someone to come and offer an industry perspective. Indeed they ended up providing some excellent insights into their experiences setting up and running large corporate hospitals during this period.

There were also various practical challenges. We had to work out the optimal seating arrangements and positions for audio recorders and negotiate with the host venue to allow tea and coffee in the seminar room. Luckily Mumbai’s monsoon rains, which had lashed the city on the day before the event and caused temporary travel disruption, just held off on the morning of the seminar, allowing people to travel freely to the venue.

The benefits of a witness seminar

With such a broad range of perspectives round the table there was a real risk that conversation would drift away from personal experiences and towards more general discussion. Prior to the event the participants had been told about the aims of the seminar and their specific contribution, and they were reminded at various points throughout the day. Barring some occasions where conversation did drift, and instances where invited audience members tried to join discussion rather than ask questions(!), the chairs did a wonderful job of keeping the seminar on-topic.

An annotated transcript from the witness seminar will be published in due course, but we can offer a flavour of some of the most insightful points here. We heard first-hand accounts of the problems that have driven medical practitioners away from working in public hospitals in Mumbai, the issues they face in institutional environments that place commercial interests over other concerns, including ‘corporate-like’ behaviours by charitable hospitals. We heard about the returns on investment rationale for industry decisions on whether to expand specific hospitals, and about how an incoming civil servant cancelled a partly-built public-private partnership hospital project. And we heard about the challenges experienced by hospitals and practitioners who have worked with health insurance schemes, public and private.

The witness seminar method offers a valuable tool for researching the healthcare sector, but our experience and those from elsewhere demonstrate that it is a challenging approach, requiring detailed knowledge about the topic to be researched, and careful and intensive planning and preparations. The method has provided a range of insights into the UK’s healthcare sector, and its use should be considered for critical research on healthcare in other settings. Certainly we’ll be using it again, in a witness seminar later in the year focusing on regulation and the private healthcare sector…

This work is part of the Practices, regulation and accountability in the evolving private healthcare sector: lessons from Maharashtra State, India, funded by the UK Medical Research Council as part of the Health Systems Research Initiative. For more information on the project click here.

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